Scott J. Mubarak

Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter.

Intracompartmental pressures were measured by the wick catheter technique in sixty-five compartments of twenty-seven patients who were clinically suspected of having acute compartment syndromes. A pressure of thirty millimeters of mercury or more was used as an indication for decompressive fasciotomy. The range of normal pressure was from zero to eight millimeters of mercury. Eleven of these patients were diagnosed as actually having compartment syndromes and in these patients, twenty-seven compartments were decompressed. Only two patients had significant sequelae. In the sixteen patients (thirty-eight compartments) whose pressures remained less than thirty millimeters of mercury, fasciotomy was withheld and compartment syndrome sequelae did not develop in any patient. Intraoperatively the wick catheter was used continuously in eight patients to document the effectiveness of decompression. Fasciotomy consistently restored pressures to normal except in the buttock and deltoid compartments, where epimysiotomy was required to supplement the fasciotomy. Continuous intraoperative monitoring of pressure by the wick catheter technique allowed us to select the few cases in which primary closure of wounds was appropriate and to decide which patients were best treated with secondary closure.

Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg

One hundred fifty-nine patients were referred to the authors for evaluation of chronic exertional leg pain from 1978 to 1987. The records of 131 patients were complete and available for retrospective review. Forty- five patients were diagnosed as having a chronic com partment syndrome (CCS) and seventy-five patients had the syndrome ruled out by intramuscular pressure recordings. The only significant difference found be tween the two groups on history and physical exami nation was a 45.9% incidence of muscle herniae in the patients with CCS, compared to a 12.9% incidence in those without the syndrome. One-third of the patients with the syndrome and over one-half of those without it reported persistent, moderate to severe pain at 6 month to 9 year followup. Modified, objective criteria were developed for the diagnosis of CCS. The criteria were based upon the intramuscular pressures recorded with the slit catheter before and after exercise in 210 muscle compartments without CCS. In the presence of appropriate clinical findings, we consider one or more of the following intramuscular pressure criteria to be diagnostic of chronic compartment syndrome of the leg: 1) a preex ercise pressure ≥ 15 mm Hg, 2) a 1 minute postexercise pressure of ≥30 mm Hg, or 3) a 5 minute postexercise pressure ≥20 mm Hg.

Intramuscular and blood pressures in legs positioned in the hemilithotomy position : clarification of risk factors for well-leg acute compartment syndrome.

Background: Acute compartment syndrome has been widely reported in legs positioned in the lithotomy position for prolonged general surgical, urologic, and gynecologic procedures. The orthopaedic literature also contains reports of this complication in legs positioned on a fracture table in the hemilithotomy position. The purpose of this study was to identify the risk factors for development of acute compartment syndrome resulting from this type of leg positioning. Methods: Eight healthy volunteers were positioned on a fracture table. Intramuscular pressures were continuously measured with a slit catheter in all four compartments of the left leg with the subject supine, in the hemilithotomy position with the calf supported, and in the hemilithotomy position with the heel supported but the calf free. Blood pressure was measured intermittently with use of automated pressure cuffs. Results: Changing from the supine to the calf-supported position significantly increased the intramuscular pressure in the anterior compartment (from 11.6 to 19.4 mm Hg) and in the lateral compartment (from 13.0 to 25.8 mm Hg). Changing from the calf-supported to the heel-supported position significantly decreased intramuscular pressure in the anterior, lateral, and posterior compartments (to 2.8, 3.4, and 1.9 mm Hg, respectively). The mean diastolic blood pressure in the ankle averaged 63.9 mm Hg in the supine position, which significantly decreased to 34.6 mm Hg in the calf-supported position. Changing to the heel-supported position had no significant effect on the diastolic blood pressure in the ankle (mean, 32.8 mm Hg). The mean difference between intramuscular pressure and diastolic blood pressure in the supine position was approximately 50 mm Hg in each of the four compartments. This mean difference significantly decreased to <20 mm Hg in the calf-supported position and then, when the leg was moved into the heel-supported position, significantly increased to approximately 30 mm Hg in all compartments. Conclusions: The combination of increased intramuscular pressure due to external compression from the calf support and decreased perfusion pressure due to the elevated position causes a significant decrease in the difference between the diastolic blood pressure and the intramuscular pressure when the leg is placed in the hemilithotomy position in a well-leg holder on a fracture table. Combined with a prolonged surgical time, this position may cause an acute compartment syndrome of the well leg. Leaving the calf free, instead of using a standard well-leg holder, increases the difference between the diastolic blood pressure and the intramuscular pressure and may decrease the risk of acute compartment syndrome.

The wick catheter technique for measurement of intramuscular pressure. A new research and clinical tool

The wick catheter technique was developed in 1968 for measurement of subcutaneous pressure and has been modified for easy intramuscular insertion and continuous recording of interstitial fluid pressure in animals and humans. Studies in dogs of the anterolateral compartment of the leg in simulation of the compartment syndrome showed the technique to be accurate and reproducible. The wick catheter technique is capable of important clinical applications in the diagnosis and treatment of acute and chronic compartment syndromes.

Double-incision Fasciotomy of the Leg for Decompression in Compartment Syndromes

Surgical decompression remains the only effective treatment for the ischemia of the muscles and nerves of the leg that constitutes the principal defects in the compartment syndromes. Recently, partial fibulectomy has been proposed as a good way to decompress all four compartments instead of the older double incision. Both methods are effective in satisfactorily reducing intracompartmental pressures, as documented by our wick catheter measurements. However, the double-incision technique is easier, faster, safer, and is the treatment of choice when four-compartment decompressive fasciotomy is indicated.

Double-blind study of botulinum A toxin injections into the gastrocnemius muscle in patients with cerebral palsy

The purpose of this study was to quantify the gait of subjects receiving two injections of either botulinum A toxin or saline vehicle into the gastrocnemius muscle(s). The study group consisted of cerebral palsy patients who walked with an equinus gait pattern. This study was a randomized, double-blinded, parallel clinical trial of 20 subjects. All were studied by gait analysis before and after the injections. There were no adverse effects. Peak ankle dorsiflexion in stance and swing significantly improved in subjects who received the drug and not in controls. Results of this double blind study give support to the short term efficacy of botulinum toxin A to improve gait in selected patients with cerebral palsy.

Acute Compartment Syndromes

A prompt diagnosis and decompression of acute compartment syndromes are essential in order to reinstate capillary perfusion and prevent irreversible sequelae. The anatomy, causes, diagnosis, and treatment of the syndrome are considered.

The Medial Tibial Stress Syndrome A Cause of Shin Splints

The medial tibial stress syndrome is a symptom com plex seen in athletes who complain of exercise-in duced pain along the distal posterior-medial aspect of the tibia. Intramuscular pressures within the posterior compartments of the leg were measured in 12 patients with this disorder. These pressures were not elevated and therefore this syndrome is not a compartment syndrome. Available information suggests that the medial tibial stress syndrome most likely represents a periostitis at this location of the leg.

Etiology of supracondylar humerus fractures

The specific etiology of supracondylar humerus fractures in children is not well known. All supracondylar humerus fractures treated at Childrens Hospital and Health Center, San Diego (CHSD) over an 8-year period (n = 391) were reviewed to determine specific information about the manner in which the injury occurred. Girls tended to sustain these fractures more often, and the nondominant arm was more often injured. Falls from a height accounted for 70% of the fractures. Children < or = 3 years old tended to fall off of household objects (beds, couches, other objects 3-6 feet high), and children 4 years and older tended to fall from playground equipment such as monkey bars, slides, and swings. Safety precautions should be implemented in homes of young children and at playgrounds to avoid these fractures.

Intramuscular pressures with limb compression clarification of the pathogenesis of the drug-induced muscle-compartment syndrome.

To study muscle necrosis due to prolonged limb compression, we measured intramuscular pressure by inserting wick catheters into 10 volar forearms and 10 anterior tibial compartments of adult volunteers. We then placed the subjects in positions in which victims of drug overdose are commonly found. Intramuscular pressures in the area of direct compression on hard surfaces ranged from 26 to 240 mm Hg, and averaged 101 mm Hg. Most remarkable was a mean pressure of 180 mm Hg on compression of the forearm by the rib cage. These pressures are sufficient to cause muscle and capillary ischemia and necrosis by local obstruction of the circulation. This local injury by limb compression may produce edema sufficient to start compartment tamponade and consequent muscle-compartment and crush syndromes.